The treatment of HIV is through antiretroviral therapy (the HIV virus is called a 'retrovirus' in medical terms). Another term for antiretroviral therapy is HAART or ART (Highly Active AntiRetroviral Therapy or AntiRetroviral Therapy). These are all terms for the same treatment: a combination of different anti-viral medicines that fight the HIV virus, or a combination of different HIV inhibitors.
When treating HIV infection, a combination of (usually three) different agents is always used. It has been shown that when only one or two HIV inhibitors are used, the virus quickly becomes resistant to the drug and then the drug no longer works.
There are now many different types of HIV inhibitors in circulation and within each type there are different individual medicines. Not every combination is suitable for every patient. Which combination of resources is chosen depends on a number of factors:
- Resistance to the HIV virus: a resistance test is always performed prior to treatment to see whether the virus you are infected with is sensitive to certain HIV inhibitors.
- Other illnesses or infections: some patients have, in addition to the HIV infection, another condition (for example, diabetes or hepatitis B infection) that makes the use of some medicines undesirable.
- The expected side effects of the individual drugs from the combination; a dreaded side effect is, for example, lipodystrophy, the disappearance of subcutaneous fatty tissue in the face and limbs. The drugs known for this side effect are avoided as much as possible.
- The number of tablets in a given combination. Some HIV inhibitors have been combined in one pill, with taking one pill you use two or even three medicines at the same time.
- Frequency of intake: some combinations require once-daily tablet intake, other combinations require twice-daily intake.
- Patient's lifestyle and rhythm of life.
When choosing the specific combination, the patient's wishes always come first. The internist and nurse consultant will only provide information about the different options and advise on the best options, but the patient ultimately decides which combination it will be.
When to start treatment?
It is a big step for most patients to start taking medication. At the moment it still looks like HIV inhibitors (ART) will have to be used for life. This is because the current generation of HIV inhibitors only suppress the HIV virus but do not completely eradicate it from the body. When the ART is stopped, the concentration of HIV virus in the blood usually quickly rises again. Many patients find it a frightening thought of having to take medicines for the rest of their lives. In addition, patients often fear the possible side effects of the ART. Many older HIV inhibitors caused lipodystrophy in some of the patients: this is a condition in which the subcutaneous fatty tissue disappears from the face and limbs and instead increases in the abdomen. This side effect is seen much less often with the newer drugs. But invisible side effects (such as an increase in cholesterol, kidney function disorders and osteoporosis) can also occur with the use of ART. It is therefore important that ART is not started unnecessarily early, but also not too late.
The decision to start HIV inhibitors depends on the following factors:
- The CD4 count:
In principle, current European and American guidelines for HIV treatment recommend starting ART when the CD4 count has dropped below 500 cells. Nowadays, there are more and more voices to start taking HIV inhibitors as soon as the diagnosis is made. In the case of an acute (newly developed) HIV infection, you hope that the HIV reservoirs are not yet full of HIV due to a quick start with medication. HIV reservoirs are places in the body where the HIV inhibitors cannot do their job because the HIV virus is present there while resting.
- Symptoms and complaints of the patient:
If someone already has clear signs of a weakened immune system (for example, a fungal infection in the mouth) it is always advised to start treatment immediately.
- Other infections (co-infections) or other conditions:
In the case of co-infection with hepatitis B or C, it can sometimes be advised to start immediately with HIV inhibitors because the medication also has a beneficial effect on hepatitis.
- Patient motivation:
Without a good motivation to start with medication, it has been found that a treatment is often less successful. With HIV inhibitors, it is important that you take the pills at about the same time each day. When a patient is not well motivated, you see that he or she more often shifts the time of intake or even forgets to take the pills for a day. If this happens more often, the virus can develop resistance to the drugs used and you will see the amount of HIV in the blood increase again.
- HIV status partner:
In some cases, the patient's partner is HIV seronegative. Starting treatment and thus an undetectable HIV viral load then reduces the chance of transmission of the virus to the partner.
- Other circumstances:
Sometimes someone wants to bring the treatment forward or postpone it because of other circumstances in his/her life, such as a vacation or a new job.
In certain circumstances the current treatment composition is changed, this is called switching. The most common circumstances to switch are:
- Viral failure: this means that the amount of HIV virus in the blood increases again despite taking medication. This is usually caused by resistance of the virus to one or more drugs of the current combination therapy.
- Side effects of one or more drugs of the current combination therapy: both noticeable side effects for the patient (e.g. severe skin rash, lipodystrophy, nausea, diarrhoea) and non-noticeable side effects (e.g. increase in cholesterol or reduced function of the kidneys) can be a reason for the medicines to change the combination.
- Improvement of old treatment: new HIV inhibitors keep coming onto the market, which is why it is possible that better medicines are now available than those the patient is currently taking. The new medicines often have fewer side effects or are easier to take (once a day instead of twice a day or two or more medicines in a combined pill).
- Other reasons such as co-infections or other concomitant diseases.
A therapy switch is always discussed in detail with the patient in advance. This conversation explains the motivation for switching and what can be expected from the new therapy. The wishes and preferences of the patient again play a major role in the choice of the new therapy. If the HIV viral load is undetectable during the switch, the current ART will continue to work; so you can always switch back.